Old Final Exam: Any Thoughts?

I was looking through some papers and found an old final exam from graduate school. I was thinking about the last question on the exam and thought of an answer that relates to diabetes. What do you think of my response? I've included links for your use; I wouldn't have included them in my answer when I actually took this exam.

Final Exam P572 – Introduction to the Learning Sciences Fall 2007

Design Question (60 pts)
1. Briefly describe a learning standard from a content domain that you are comfortable.
2. Identify 3 of Gee’s Learning Principles that are most important to a learning activity/environment for this standard.
3. Describe the key elements and activities of the learning environment that embody these three Learning Principles.
4. Explain how the 3 Learning Principles informed the design of this learning environment.

One core component of diabetes self-management education curriculum (DSME) is learning to perform self-monitoring of blood glucose (SMBG) activities. Of all the activities involved in diabetes management, this one activity, which can take as little as 30 seconds from start to finish, is perhaps the most cognitively demanding. As Mulachy et al (2003) state, SMBG “requires a combination of technical skills and cognitive skills, including the ability to interpret results that allow patients and their health care team to evaluate individual responses to therapy to assess if glycemic targets are being achieved” (p.xxx). What does a 280 mg/dl blood glucose reading mean? Does a 65 mg/dl reading mean the patient is “safe” to drive or “unsafe”? At what point should she or he treat an insulin reaction? The purpose of DSME is to help provide patients with the skills to help answer such questions and to allow them to take appropriate action to maintain their health and keep themselves (and others) safe. Among the learning standards most diabetes educators would have that relate to SMBG directly perhaps the most important for this discussion is the appropriate interpretation of SMBG results. Not understanding the results can have dire consequences, such as believing one’s blood glucose is quite high, leading him/her to inject far more insulin than s/he needs, leading to a potentially lethally low blood sugar, or underestimating insulin needs, leading to chronically high blood sugars and the long-term complications that come with that (e.g. foot amputations). Therefore, it is in the best interest of all stakeholders to have an educational program that promotes this understanding and encourages appropriate action.

Three principles of Gee’s I believe are most important to this outcome are: 1) The Semiotic Principle; 2) The Probing Principle; and 3) The Psychosocial Moratorium Principle. The Semiotic Principle proposes that effective learning environments need to help learners appreciate the interrelationships within and across multiple sign systems. For example, in mathematics students need to learn that ½ = 50% = 0.5 = one-half. They are all the same concept, but expressed differently, using different symbol systems. This principle is best exemplified in DSME when teaching people with diabetes how to test their blood and use the results of decision-making purposes. As Gee points out, when people learn to play video games, they need to learn to “read” the game – to make sense of the symbols, graphs, and other artifacts found within the game and how these symbols relate to one another. Similarly, persons with diabetes need to learn to “read” their bodily symbols/signs and to make sense of the numbers that pop up on their blood glucose meters. People with diabetes need to ask if the sweaty palms and racing heart are due to pre-recital nerves or a low blood sugar? Does the 350 fasting reading mean one’s insulin is bad, an extreme low happened overnight, too much cake was consumed the night before, or the cat pulled out the infusion site – or could it be some combination of these issues? If all the person knows are the numbers in isolation, if she cannot place these numbers into some sort of context, it will be very difficult (if not impossible) to make independent decisions about treatment – which, unlike treatment for pneumonia, can change from day-to-day. Therefore, the Semiotic Domain Principle is quite important when designing an environment for SMBG education.

The second principle I chose is The Probing Principle. Gee proposes that learning is a cycle of action, reflection, hypothesis formation, further action, and more reflection that he calls “probing”. All good video games make some allowances for this and often times, players who fail to reflect on their actions fail to advance through the game. Success happens when people stop to consider the consequences of the actions they have already taken. Baseball and football teams, as well as marching bands, have been using videos of themselves and their competition in order to probe both success and failures for the past several decades. Video game companies such as Blizzard Entertainment have incorporated “playbacks” for players so people can improve their performance within the game.

This principle also needs to be employed in SMBG education. For instance, in 2008-2009, I found myself having multiple hypoglycemic episodes, sometimes daily, sometimes multiple times each week, most often in the morning. If one uses Bransford and Stein’s Ideal Problem Solver model, I had identified a problem – thanks to SMBG and being able to make sense of the numbers. The question then became “Why?” and, with the help of a registered dietitian, we defined the problem as using too much insulin for the number of carbohydrates I was eating. We then explored the most viable options to correct the problem: Increase the number of carbohydrates per meal I ate or decrease the amount of insulin I was taking. We chose the latter and changed my breakfast insulin dosage from 1 unit of insulin per 15 grams of carbohydrates (1:15) insulin:carbohydrate ratio to 1:18. We expected my blood glucose levels would go up and I would have fewer incidents of low blood sugars. After a few weeks of eating this way, testing, and recording the results (Act, in Bransford and Stein’s terms), it became apparent that the 1:18 ratio was still too much insulin for me (Look and learn, vis-à-vis Bransford and Stein, 1993) and we changed the ratio to 1:19-1:20, depending on whether or not I intended to exercise that morning. To make sure this was the right amount of insulin, we repeated the cycle of testing, recording, and questioning – exactly as Gee recommends, and an important component of the Probing Principle.

The third and final principle I propose as most important for SMBG learning is the Psychosocial Moratorium Principle. Taken from Erik Ericksen’s personality developmental stage theory (adolescent/young adult stage), Gee describes this principle as one in which the environment allows learners to take risks, but in which the real-world consequences are lowered. Diabetes management (and it lack thereof) can have devastating, disabling, even fatal consequences. Mixing alcohol and diabetes medications can lead to dangerous hypo and hyperglycemic (low and high blood sugar) excursions. Skipping meals, not eating on a (relatively) fixed schedule, or not consuming approximately the same number of carbohydrates every day can also cause problems. Yet, it is unrealistic to expect a person to eat exactly the same foods, to get the exact same amount of activity, so as to take precisely the same amount of insulin day-in and day-out. Yet, if the person with diabetes fails to take these risks, she or he will not learn how what works and what does not. At the same time, though, trying new things is fraught with potential problems. I can say from personal experience that I was quite anxious when I was experimenting with my insulin-to-carbohydrate ratios, even though the goal was to lessen the frequency of the lows. Currently, the only way for people with diabetes to tinker with [1] their diabetes management tools and learn about their problem is to perform these activities in vivo, which carries serious, sometimes unacceptable risks. Given this, having a space in which to practice and learn about diabetes management in which the risks of taking chances are lowered would seem to be a requirement for learning to manage one’s diabetes.

One way I propose to fill this void is to develop a video game revolving around diabetes management. Using Second Life or Quest Atlantis type avatars with the compelling story line of World of Warcraft or Battlestar Galactica can allow the player/patient to become engaged in a world in which the risk of running a 5k race or skipping lunch are substantially reduced. Players could take risks they otherwise might not take in real life while quickly receiving feedback about their decisions. Having built-in prompts to encourage reflection (“Is eating that chocolate cake without any insulin really a good idea?”) would fulfill the probing principle, while other prompts and choice point could provide learners with the opportunity to explore multiple management options, which could help fulfill the Semiotic Domains principle. Finally, replay and reflection prompts can also be built in that help learners to stop and reflect on what they have done, why the outcomes have happened, and what they can do to improve their performance, which fulfills the Probing Principle. For these reasons, I believe a video game, developed with an eye toward Gee’s principles, could be an effective learning environment.

Bransford, J.D. and Stein, B.S. (1993). The Ideal Problem Solver. NY: Worth Publishers.

Gee, J.P. (2003). What Video Games Have To Teach Us About Learning and Literacy. NY: Palgrave Macmillan.

Mulcahy, K., Maryniuk, M., Peeples, M., Peyrot, M., Tomky, D., Weaver, T., Varborough, P. (2003). Technical review: Diabetes self-management education core outcomes measures. The Diabetes Educator, 29, 768-803.

[1] See http://tinyurl.com/5s9rs7p, John Seely Brown SOTL lecture at Indiana University. JSB describes learning as a process of “tinkering” with an area of practice, and this seems quite apt, in particular for diabetes education.